Healthcare Provider Details

I. General information

NPI: 1649381690
Provider Name (Legal Business Name): RAMESH SHATAGOPAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1429 N 6TH ST
TERRE HAUTE IN
47807-1037
US

IV. Provider business mailing address

221 S 6TH ST
TERRE HAUTE IN
47807-4214
US

V. Phone/Fax

Practice location:
  • Phone: 812-232-0564
  • Fax: 812-242-3543
Mailing address:
  • Phone: 812-242-3175
  • Fax: 812-242-3543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01048847A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number36111955
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: